- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.30 / $97.45 / $103.71
| Professional | | $90.30 | $97.45 | $103.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.05 / $105.05 / $105.05
| Facility | | $105.05 | $105.05 | $105.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.41 / $105.05 / $105.05
| Professional | | $89.41 | $105.05 | $105.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.41 / $105.05 / $108.98
| Facility | | $89.41 | $105.05 | $108.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.00 / $97.00 / $126.52
| Professional | | $97.00 | $97.00 | $126.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.41 / $89.41 / $89.41
| Professional | | $89.41 | $89.41 | $89.41 |